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New and improved RACs

During the CMS Hospital/Quality Initiative Open Door Forum call on February 24, 2015, CMS issued a 4-page document summarizing the improvements it has implemented to the RAC program [PDF]. CMS introduced 20 changes to address concerns raised by the provider community, tighten oversight of the RACs, and increase transparency. These revisions will become effective with each new RAC contract awarded:

CMS will base record request limits on a provider’s denial rates and adjust the limits as denial rates change.

CMS will reduce the look-back period from 3 years to 6 months for hospitals that submit claims within 3 months of the date of service.

CMS will establish limits that are diversified across all claim types to avoid disproportionately impacting one claims type.

CMS will incrementally apply the limits to new providers under review.

CMS will not increase the limits for physicians at the beginning of the new RAC contracts.

RAC audits will not necessarily be conducted by physicians of the same specialty, but RACs are encouraged to have a panel of specialists available for consultation.

RACs will wait 30 days to allow for a discussion period request before sending the claim to the MAC for adjustment.

RACs will confirm receipt of a provider’s discussion period request within 3 business days.

CMS will work with the RACs to make their provider portals more uniform and consistent.

PIP providers will not be negatively impacted with improper payment adjustments.

RACs will not receive any fee until after the second level of appeal.

CMS will publicize more information about the RACs.

RACs will broaden their review topics to include all claim/provider types.

RACs that do not maintain a reversal rate of less than 10% at the first level of appeal will face a corrective action plan that could include decreasing the limits or ceasing certain reviews.

RACs that do maintain an accuracy rate of at least 95% for automated review will face a progressive reduction in the limits.

A Provider Relations Coordinator will field an address questions and complaints.

CMS will continue to post Provider Compliance Tips to its website so providers can avoid negative findings.

RACs will provide consistent and more detailed information about the review topics.

CMS will consider developing a Provider Satisfaction Survey.

Ober|Kaler's Comments

These changes should result in fewer patients charts being audited in a shorter time period. However, although this list appears exhaustive and generous, CMS actually declined to change the one substantive issue that could have truly yielded meaningful improvements. In reviewing a claim for services rendered by a particular specialist, CMS refused to require each RAC to conduct that review utilizing a physician reviewer of the same specialty. It will be interesting to see how many RACs are required to submit a corrective action plan due to their high overturn rate.